Enroll now for 2019 insurance coverage!

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1 A not-for-profit ministry of Church of the Brethren Benefit Trust Inc Dundee Avenue Elgin, Illinois Fax Enroll now for 2019 insurance coverage! Nov is the open enrollment period for Dental, Vision, and Medicare Supplement coverage effective Jan. 1, Plan members with current coverage will be automatically renewed unless we are notified by you of any changes. In this packet, you will find information about the following: Dental and Vision You may choose among three dental and three vision coverage options for If you elect to change to a new plan option, you must complete a new enrollment form. If you elect to keep your current dental and/or vision plan, your coverage will automatically renew; no forms need to be submitted and you will continue using your current ID cards. Enrollment Forms Summaries of Benefits Rate Sheet Retiree Life Insurance If you are currently enrolled in Retiree Life insurance, your coverage will automatically renew rate sheet for Retiree Life will be mailed separately to those currently enrolled. Medicare Supplement Plan Summary of Benefits and Rate sheet our insurance carrier remains with United American. Please continue using your current ID card if you wish to keep your current plan. No forms are required. We have added a new plan option, which is explained on the Introducing Medicare Supplement Plan G page. Option 1 Option 2 NEW for 2019 Plan F $20 Co-pay Plan G If you wish to change coverage, you may do so now by completing and returning the enrollment form. NOTE: Plan options are limited by state law for members with a permanent address in the states of Washington or Florida. If you missed signing up for Medicare Supplement insurance during the 6-month enrollment period that immediately follows your Medicare eligibility date, you now have a one-time opportunity to do so. Anyone who is an active or retired Church of the Brethren employee (as well as Medicare-eligible spouses), age 65 or over, and enrolled in Medicare Parts A and B, is eligible to enroll. This is a good time to review which option best meets your needs call us if you have questions. If you are enrolling in new coverage or making any changes to your current coverage, please complete the forms and mail them to Brethren Insurance Services in the enclosed, pre-addressed envelope postmarked no later than Nov. 30, Please contact Connie Sandman at , ext. 3366, or us at insurance@cobbt.org if you have any questions. You may visit our website at cobbt.org/open-enrollment for additional information and forms. Thank you for choosing Brethren Insurance Services for your insurance needs. It is our privilege to serve you! 2019RetireeAncillaries

2 A not-for-profit ministry of Church of the Brethren Benefit Trust Inc Dundee Avenue Elgin, Illinois Fax Annual Deductibles Delta Dental PPO INSURANCE COMPANY : Delta Dental GROUP NUMBER : CUSTOMER SERVICE : WEB SITE : NETWORK : PPO and Premier Voluntary Dental Insurance Triple Option Plan Option 1 Option 2 Option 3 Delta Premier **Non- Delta Dental **Non- Delta Dental Delta Premier Network PPO Network PPO Delta Premier **Non- Network Individual $0 ** Non-Network services are subject to U&C/R&C limitations. The Patient will be responsible for any charges over these limits. $0 $0 $50 $50 $50 $50 $50 $50 Family $0 $0 $0 $150 $150 $150 $150 $150 $150 Maximum Annual Benefit per Insured $2,000 $1,500 $1,000 Dependent Age Limit Up to age 26 Up to age 26 Up to age 26 New Hire Waiting Period None None None Late Entrant Waiting Period None None None Covered Expenses Preventive Services 100%* 100%* 100%* 100%* 100%* 100%* 100%* 100%* 100%* *Deductible Waived Oral Exams (two per calendar year) Oral Exams (two per calendar year) Oral Exams (two per calendar year) Cleanings (two per calendar year) Cleanings (two per calendar year) Cleanings (two per calendar year) X-Rays X-Rays X-Rays Space Maintainers to age 19 Space Maintainers to age 19 Space Maintainers to age 19 Fluoride Treatments to age 19 Fluoride Treatments to age 19 Fluoride Treatments to age 19 Sealants to age 16 Sealants to age 16 Sealants to age 16 Basic Services 80% 80% 80% 80% 80% 80% 80% 80% 80% Fillings Fillings Fillings Oral Surgery Oral Surgery Oral Surgery Extractions Extractions Extractions Endodontics (root canal) Endodontics (root canal) Endodontics (root canal) Non-Surgical Periodontics (gum treatment) Non-Surgical Periodontics (gum treatment) Non-Surgical Periodontics (gum treatment) Major Services 50% 50% 50% 50% 50% 50% 50% 50% 50% Surgical Periodontics (gum treatment) Surgical Periodontics (gum treatment) Surgical Periodontics (gum treatment) Inlays and Onlays Inlays and Onlays Inlays and Onlays Crowns Crowns Crowns Dentures Dentures Dentures Bridges Bridges Bridges Implants Implants Implants Orthodontia (Child Only to age 19) 50% 50% 50% 50% 50% 50% 50% 50% 50% Maximum Lifetime Orthodontia Benefit per child $3,000 $1,500 $1,000 This summary is intended to highlight your benefits and should not be relied on to fully determine coverage. Please refer to your certificate of coverage for a complete outline of covered services, limitations, and exclusions. Benefits are subject to change based on local and state mandated laws. Benefit information listed in your carrier certificate always supersedes any information provided in this benefit summary.

3 Completed forms must be returned to Brethren Insurance Services WITHIN 31 DAYS OF YOUR HIRE DATE. If you miss the initial 31-day enrollment period, you may be eligible for late enrollment for life and/or disability coverage. Also, keep in mind that we offer an annual open enrollment for our dental, vision, life and AD&D, long- and short-term disability, and accident plans. ALL GROUPS MUST COMPLETE THIS SECTION Note: Incomplete forms will be returned. Delta Dental Group Number Church Code (if applicable) Hourly Salaried Effective Date Date of Hire OR Date of Rehire Other Name of Employer Annual Salary PLEASE LIST ALL ELIGIBLE DEPENDENTS TO BE COVERED (Child up to age 26) ADD DELETE FIRST NAME LAST NAME (if different) BIRTH DATE (M/D/Y) SEX (M or F) SSN 1. Spouse: 2. Child: I agree to continue enrollment until canceled due to IRS-qualifying event or canceled by me during annual open enrollment. I further authorize applicable payroll deduction, where available, for premiums due. Signature of Employee: Date: Signature of Employer: Date: Delta Dental of Illinois A not-for-profit ministry of Church of the Brethren Benefit Trust Inc Dundee Avenue Elgin, Illinois Fax insurance@cobbt.org

4 UV Coating 20% discount N/A 20% discount N/A 20% discount N/A Tint (solid and gradient) 20% discount N/A 20% discount N/A 20% discount N/A Standard Scratch Resistant 20% discount N/A 20% discount N/A 20% discount N/A A not-for-profit ministry of Church of the Brethren Benefit Trust Inc Dundee Avenue Elgin, Illinois Fax insurance@cobbt.org INSURANCE COMPANY : EyeMed Vision Plan GROUP NUMBER : CUSTOMER SERVICE : WEB SITE : eyemedvisioncare.com NETWORK : Select Frequency EyeMed Member Doctor Voluntary Vision Insurance Triple Option Plan Option 1 Option 2 Option 3 Non-EyeMed EyeMed Non-EyeMed EyeMed Member Doctor Member Doctor Member Doctor Member Doctor Examinations Once every 12 months Once every 12 months Once every 12 months Lenses* Once every 12 months Once every 12 months Once every 12 months Frames* Once every 24 months Once every 24 months Once every 12 months Benefits Non-EyeMed Member Doctor Examination $10 copay up to $35 $10 copay up to $35 $10 copay up to $35 Single Vision Lenses $25 copay up to $25 $25 copay up to $25 $10 copay up to $25 Bifocal Lenses $25 copay up to $40 $25 copay up to $40 $10 copay up to $40 Trifocal Lenses $25 copay up to $60 $25 copay up to $60 $10 copay up to $60 Frames Lens Options $120 allowance then 20% discount up to $48 $100 allowance then 20% discount up to $40 $140 allowance then 20% discount up to $56 Standard Polycarbonate 20% discount N/A 20% discount N/A Covered in full up to $28 Standard Progressive (bi-focal) $25 copay, then 80% of charge less $55 allowance up to $40 $25 copay, then 80% of charge less $55 allowance up to $40 $10 copay, then 80% of charge less $120 allowance Standard Anti-Reflective Coating 20% discount N/A 20% discount N/A 20% discount N/A Other Add-Ons and Services 20% discount N/A 20% discount N/A 20% discount N/A Contact Lenses* Conventional up to $135 then 15% discount up to $95 up to $115 then 15% discount up to $81 up to $155 then 15% discount up to $85 up to $109 Disposables up to $135 up to $95 up to $115 up to $81 up to $155 up to $109 LASIK Surgery 5% to 15% discount N/A 5% to 15% discount N/A 5% to 15% discount N/A Dependent Age Limit Up to age 26 Up to age 26 Up to age 26 *Service Restriction: Plan allows the member to receive either contacts and frame, or frame and lens services This summary is intended to highlight your benefits and should not be relied on to fully determine coverage. Please refer to your certificate of coverage for a complete outline of covered services, limitations, and exclusions. Benefits are subject to change based on local and state mandated laws. Benefit information listed in your carrier certificate always supersedes any information provided in this benefit summary.

5 EMPLOYER INFORMATION: Group Number Employer Name Enrollment/Change Form Please print and complete all sections. See instructions below. Underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri Plan Selection Option 1 Option 2 Option 3 Hire Date Effective Date EMPLOYEE INFORMATION ADD TERM CHG Sex M F Member ID (SSN) Last Name First Name MI Date of Birth Home Street Address City/State/ZIP+4 Home Phone ( ) FAMILY INFORMATION (Only those eligible may be enrolled.) A: Add (enroll) T: Terminate C: Change (change of name) A T C Sex M F Last Name (spouse) First Name MI Date of Birth Social Security Number A T C A T C A T C A T C Sex M F Sex M F Sex M F Sex M F Last Name (dependent) First Name MI Date of Birth Social Security Number Last Name (dependent) First Name MI Date of Birth Social Security Number Last Name (dependent) First Name MI Date of Birth Social Security Number Last Name (dependent) First Name MI Date of Birth Social Security Number I agree to continue enrollment until canceled due to IRS-qualifying event or canceled by me during annual open enrollment. I further authorize applicable payroll deduction, where available, for premiums due. Employee Signature: Date: Employer Signature: Date: Instructions: Effective date: The day you become eligible. Family Information: List only eligible family members who are enrolling. Dependent eligibility is up to age 26. (A) Add: Open enrollment or new hire. (T) Terminate: To terminate enrollment. (C) Change: A change of name, employee address or employee phone. Completed forms must be returned to Brethren Insurance Services WITHIN 31 DAYS OF YOUR HIRE DATE. If you miss the initial 31-day enrollment period, you may be eligible for late enrollment for life and/or disability coverage. Also, keep in mind that we offer an annual open enrollment for our dental, vision, life and AD&D, long- and short-term disability, and accident plans. A not-for-profit ministry of Church of the Brethren Benefit Trust Inc Dundee Avenue Elgin, Illinois Fax insurance@cobbt.org

6 C H U R C H O F T H E B R E T H R E N INSURANCE SERVICES A not-for-profit ministry of Church of the Brethren Benefit Trust Inc Dundee Avenue Elgin, Illinois Fax insurance@cobbt.org Monthly Rates Dental and Vision (Retirees Group) To enroll in any of these plans, please ensure that eligibility requirements have been met, complete the appropriate enrollment form, and return to Mail: Brethren Benefit Trust, 1505 Dundee Ave., Elgin, IL 60120; Fax: ; or insurance@cobbt.org Delta Dental Plan Option 1 Option 2 Option 3 Employee $ $ $ Employee + One Employee + Family EyeMed Vision Plan Option 1 Option 2 Option 3 Employee $ $ $ Employee + One Employee + Family BISRetireeDentalVisionRates2019

7 A not-for-profit ministry of Church of the Brethren Benefit Trust Inc Dundee Avenue Elgin, Illinois Fax Monthly Rates Medicare Supplement Benefit Highlights Inpatient Hospital Part A Deductible Inpatient Skilled Nursing Facility Outpatient Part B Deductible Hospice Care Emergency Care Urgent Care Facilities Ambulance Physician Office Visit Charges Preventive Care Primary Care Physician Specialist Plan Lifetime Maximum United American Insurance Co. Plan F through 365 days through 100th day Unlimited United American Insurance Co. $ 20 Co-pay through 365 days through 100th day $ 20 copay $ 20 copay Unlimited United American Insurance Co. Plan G through 365 days through 100th day $ 183 deductible, then Unlimited Age at time of Enrollment Plan F (Option 1) $ 20 Co-pay (Option 2) Plan G < Washington ALL AGES Maryland ALL AGES $ $ $ $ $ $ N/A $ $ $ $ $ $ $ $ $ N/A $ $ $ $ $ $ $

8 Some background to begin Introducing Medicare Supplement Plan G As you know, Medicare does not pay 100 percent of your medical expenses when you are 65 or older. It pays 80 percent of Medicare Part A (hospital costs) and 80 percent of Part B (doctor, surgical, and outpatient costs). You would need to buy Medicare Supplement (med supp) insurance to cover the rest. After offering Plan F med supp for many years, Brethren Insurance Services will begin in 2019 to offer Plan G. This comes at a time when more and more people 65 and older are also hearing about and considering Plan G, which offers lower premiums in exchange for your willingness to share more of the cost. But Plan G is not new and has been around for a long time. Why the interest now? The cost of healthcare has been rising. Employers and individuals have been drawn to plans with lower premiums and are willing to accept a little cost-sharing. People under 65 who are still on group and individual plans have gotten used to instruments such as health savings accounts, which give them a cushion that allows them to buy plans with lower premiums and higher deductibles. How is Plan G different from Plan F Plan F has been popular for so long because it offers full coverage. But Plan F premiums are high. Baby boomers aging into Medicare are looking for lower premiums, are more open to cost-sharing, and are thus willing to consider deductibles. Plan G is like Plan F, except with a lower premium and with a small yearly deductible. People are comfortable with Plan F because they know they will owe nothing. It covers all hospital and outpatient costs not covered by Medicare. On the other hand, people like the idea of paying a lower premium each month. This is where Plan G comes in. For a lower premium, it covers everything Plan F covers except the Part B deductible (doctors, surgeries, outpatient services, etc.). That deductible for 2019 is $183, which means you have to pay the first $183 of Part B costs before your insurance begins to pay. How they really compare Let s take an example, using the 2019 Medicare supplement monthly rates just published by Brethren Insurance Services. If you are between 66 and 69, your Plan F monthly premium would be $ Your Plan G monthly premium would be $ That s a difference of $18 per month, or $216 per year you would save with Plan G. But remember you will have to pay the first $183 of your Part B medical costs, so you will have to subtract that giving you a net savings of $33 by using Plan G. Also, remember that after the deductible is met, the coverage in Plan G is identical to that of Plan F. This same comparison and analysis works for all other age levels in Plans F and G from Brethren Insurance Services as well. You will always find that Plan G will result in a small savings.

9 Other reasons for Plan G There is another way Plan G might be worth your consideration. Plan G is attractive for those people who rarely go to the doctor. In this instance, people not only have lower premiums, but they never need to pay their deductible. A big change coming for Plan F in 2019 For Brethren Insurance Services in 2019, the numbers fall favorably for Plan G. However, there is one more factor. Medicare will sunset Plan F at the end of That means they will phase it out. The year 2019 is the last time you can sign up for Plan F. If you already have Plan F, you may keep is as long as you wish, but if you make any changes you will lose it. Brethren Insurance Services Medicare Supplement options for 2019 For all these reasons, Brethren Insurance Services will begin to offer Plan G in It will also continue to offer Plan F until the end of the year and beyond for those that remain enrolled in the product. Further, BIS also offers a third option Plan F with co-pay. This option has lower premiums, but you will pay the first $20 for all visits to primary care physicians and specialists. This option will save you money only if you have few or no doctor visits. In this respect it is like Plan G, except that there is no ceiling on how much you will expend in co-pays. There are no worries! There has been some anxiety about these changes on the part of people who have been long-time policyholders of BIS Medicare Supplement insurance. Brethren Insurance Services wants to assure you that these changes will not affect you if you wish to keep the coverage you have had. If you prefer the Plan F policy you have had for a long time, you can keep it as long as you wish.

10 A not-for-profit ministry of Church of the Brethren Benefit Trust Inc Dundee Avenue Elgin, Illinois Fax Medicare Supplement Plan Enrollment This is an enrollment form for Medicare supplement coverage provided by Brethren Medical Plan. If your employer has 20 or more employees, the medical plan provided by your employer will be primary, and Medicare will be secondary. If your employer has fewer than 20 employees, Medicare will be primary, and the Brethren Medical Plan Medicare Supplement Plan will be secondary. EMPLOYEE INFORMATION Active, inactive, or retired employee (complete if enrolling for coverage) Employee/Retiree Last Name First Name MI Employee/Retiree Address City State ZIP - Phone We will use your address solely to communicate with you about Brethren Insurance Services. Birth Date Social Security Number Marital Status: Single Married If married, is your spouse now enrolled in the Brethren Medical Plan Medicare Supplement Plan? Yes No EMPLOYEE COVERAGE APPLIED FOR Check one: Plan F (Option 1) $20 Co-pay (Option 2) Plan G (New for Jan 1, 2019) Employment Status Active employee eligible for Medicare Are you on Medicare disability? Yes No date of disability Employer Does your employer have 20 or more employees? Yes No Inactive employee under age 65 Are you on Medicare disability? Yes No Previous Employer date of disability Retired employee Are you on Medicare disability? Yes No Date of Hire Hours worked per week Date of retirement date of disability Previous Employer What is the Medicare Claim Number shown on your Medicare card? / / Are you covered under Medicare, Parts A (hospitalization) and B (medical)? Yes No What is the effective date shown on your Medicare card? SPOUSE INFORMATION Spouse of active, inactive, or retired employee (complete if enrolling for coverage) Spouse s Last Name First Name MI Spouse s Birth Date Spouse s Social Security Number Page 1 MedSupp2019RET.qxp

11 SPOUSE COVERAGE APPLIED FOR Check one: Plan F (Option 1) $20 Co-pay (Option 2) Plan G (NEW; effective date Jan. 1, 2019) Status Spouse of active employee Spouse of inactive employee under age 65 Spouse of retired employee Are you on Medicare disability? Yes No date of disability What is the Medicare Claim Number shown on your Medicare card? Are you covered under Medicare, Parts A (hospitalization) and B (medical)? What is the effective date shown on your Medicare card? / / Yes No OTHER COVERAGE To the best of your knowledge 1. Are you currently enrolled in the Brethren Medical Plan? 2. Do you currently have another Medicare supplement policy in force? 3. Do you intend to replace your current Medicare supplement policy with the Brethren Medical Plan Medicare Supplement Plan? 4. Do you have any other health insurance coverage that provides benefits similar to the Brethren Medical Plan Medicare Supplement Plan? Retiree/Employee Spouse Yes No Yes No If you answered yes to question 2 or 4, please give the following information Other insurance information Date coverage began Date coverage ended Type of policy Insurance Company Name: Insurance Company Address: Insurance Company Telephone Number: Insurance Company Name: Insurance Company Address: Insurance Company Telephone Number: SIGNATURES Please read and sign below if enrolling for coverage. I understand that to enroll in this plan, I: 1. Must be covered under Medicare, Part A (hospitalization) and Part B (medical). 2. Must be a Medicare-eligible employee or retiree of a Church of the Brethren-affiliated employer. I authorize all health care providers to release any necessary medical information to BBT to process claims. I understand that this information will be shared with third parties only if necessary for managing or processing claims. I am responsible to notify Brethren Benefit Trust of any changes in the above information. Signature of Active, Inactive, or Retired Employee Date Signature of Spouse of Active, Inactive, or Retired Employee (if enrolling) Date Page 2 MedSupp2019RET.qxp

12 A not-for-profit ministry of Church of the Brethren Benefit Trust Inc Dundee Avenue Elgin, Illinois Fax Authorization Agreement for Automatic Payment BANK INFORMATION I hereby authorize BRETHREN BENEFIT TRUST INC. to withdraw funds on the first business day of each month from this account for payment of insurance premiums. Bank Name Phone City State ZIP o Checking Routing Number (9 digits) Account Number o Savings Please attach a voided check for your checking account or a deposit slip for your savings account. TO BE COMPLETED BY THE PLAN MEMBER OR EMPLOYER This authority is to remain in full force and effect until BRETHREN BENEFIT TRUST INC. has received written notification from my/our authorized representative of its termination in such manner as to afford BRETHREN BENEFIT TRUST INC. and my bank a reasonable opportunity to act on it. Retiree Member Last Name First Name MI Or Employer Name Employee Name Phone Number We will use your address solely to communicate with you about Brethren Insurance Services. ocheck here if you wish to receive your invoice via . Church Code When you sign up for automatic payments, your monthly premium will be deducted on the first business day of each month from your bank account. OR Agreement # Signature of Plan Member (or Employer Representative) Date RETURN THIS FORM VIA Mail: Brethren Benefit Trust Inc., 1505 Dundee Ave., Elgin, IL Fax: insurance@cobbt.org For Office Use Only o Startup Request or o Change Request Effective Date: Entered by: Date: Verified by: Date: I-BISAuthAgrmntAP.qxp

13 Long-term care for your peace of mind When John and Helen Wenger of Anderson (Ind.) Church of the Brethren thought about their lifetime accumulations, they wanted to protect their assets while making sound plans for the future. We hope to live at a Brethren retirement community like Timbercrest, and long-term care insurance will allow us to do that. As Brethren, we re called to be good stewards our relationship with BBT provides that. Long-Term Care Insurance is available to all Church of the Brethren employees and members, as well as their families and friends. Long-Term Care Insurance Information Request By filling out this form, I understand that a representative from Brethren Insurance Services will contact me about receiving a free, no-obligation Proposal for Long-Term Care Insurance. Client s name Date Address City State ZIP Home phone Cell phone Best time to call: A.M. P.M. Date of birth Age Height Weight Married: Yes No Tobacco use within last 5 years: Yes No Comments: Please hand this completed form to the BBT representative or mail it to the address below. A not-for-profit ministry of Church of the Brethren Benefit Trust 1505 Dundee Ave., Elgin, IL website: toll-free fax insurance@cobbt.org

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